Technical considerations in adult lung transplantation

Technical aspects of reconstruction for inadequate left atrial cuff in lung transplantation

OBJECTIVE

Lung transplantation is the only life-saving treatment for lung diseases that do not respond to medical treatment. Heart-lung harvesting requires a careful procedure to protect an adequate donor left atrial cuff around the junction of the superior and inferior pulmonary veins. This study aims to describe inadequate left atrial cuff during harvest and techniques of reconstruction at the threshold of literature.

METHODS

Left atrial cuff complications were retrospectively analyzed in consecutive lung transplant procedures between December 2016 and December 2021. Donor and patient demographics, reconstruction material and method of application and postoperative follow-up were examined.

RESULTS

In the study period, 84 consecutive lung transplant procedures were performed. Reconstruction of the inadequate left atrial cuff was 3.7% (6/162) for atrial anastomoses. However, the inadequate left atrial cuff was 9.1% (5/55) in heart-lung harvesting. Donor aorta graft was used in 4 patients and Dacron mesh was used on the bilateral atrial cuff in one patient. Hospital mortality occurred in one patient. One patient died 6 months later due to antibody-mediated rejection. The follow-ups of the other three patients are continuing without any problems.

CONCLUSIONS

Inadequate left atrial cuff complications occurring in heart-lung harvest seem to be more common than in the literature. Techniques of reconstruction for the inadequate left atrial cuff is vital for the patient who has reached irreversible progress in surgery for the recipient, as well as increasing the number of organs.

Single-lung and double-lung transplantation: technique and tips

The first successful single-lung and double-lung transplantations were performed in the eighties. Since then both surgical and anesthesiological management have improved. The aim of this paper is to describe the surgical technique of lung transplantation: from the anesthesiological preparation, to the explantation and implantation of the lung grafts, and the preparation of the donor lungs. We will also describe the main surgical complications after lung transplantation and their management. Each step of the surgical procedure will be illustrated with photos and videos.

Left Ventricular Dysfunction After Lung Transplantation for Pulmonary Arterial Hypertension

BACKGROUND

Lung transplantation (LT) is the final treatment option for patients with pulmonary arterial hypertension (PAH). Perioperative challenges after LT are unique and commonly include excessive bleeding, arrhythmias, and primary graft dysfunction. Transient left ventricular dysfunction (LVD) is a known postoperative complication, but not fully explored. We describe our experiences at a single institution.

METHODS

We reviewed our database for patients with PAH who underwent LT from July 2008 to July 2012. The data were analyzed for preoperative inotrope use, intravenous prostacyclin, cardiac catheterization, and imaging. Also measured were perioperative ischemic time, bypass time, primary graft dysfunction, ventilator days, length of stay, and mortality. LVD is defined as acute cardiopulmonary compromise (acute worsening of hypoxia with new bilateral infiltrates on imaging) with a drop in LV systolic function of 15% from baseline. We compared data between patients with LVD and without LVD.

RESULTS

Sixteen patients met the criteria, the majority of patients (10) with World Health Organization (WHO) group 1 PAH. Thirteen received intravenous prostacyclin therapy, and 6 required inotropes before surgery. Five patients (31%) developed LVD after transplantation. Average time to onset of LVD was 4.2 days. Preoperative vasopressors were required in 60% of those developing LVD. Patients with LVD had lower right and left ventricular ejection fraction with higher left ventricular end diastolic volume before surgery. All patients recovered from LVD within 4 months after LT.

CONCLUSIONS

LVD is a phenomenon observed mostly in patients with WHO group 1 PAH receiving LT. Prompt recognition and treatment of this condition reduced morbidity.

Pulmonary artery patch for an inadequate donor atrial cuff in the absence of donor pericardium in lung transplantation

In cadaveric lung transplantation (LTx), a donor lung with an inadequate donor left atrial cuff is considered a "surgically marginal donor lung". The donor pericardium is commonly applied to reconstruct the inadequate donor left atrial cuff; however, in some cases, the donor pericardium is inadvertently removed during the lung procurement. We devised an alternative technique for reconstruction to overcome the absence of pericardium in a donor lung with an inadequate atrial cuff, using a patch of the donor pulmonary artery (PA) in single lung transplantation. In a recent case of lung transplantation in which the donor pericardium had been removed, we harvested a segment of the right PA distal to the main PA of the donor and used a PA patch to repair the inadequate donor left atrial cuff. No vascular complications were encountered in the recipient, who remains in good health after the transplantation.

MECHANICAL VENTILATION FOR THE LUNG TRANSPLANT RECIPIENT

Mechanical ventilation (MV) is an important aspect in the intraoperative and early postoperative management of lung transplant (LTx)-recipients. There are no randomized-controlled trials of LTx-recipient MV strategies; however there are LTx center experiences and international survey studies reported. The main early complication of LTx is primary graft dysfunction (PGD), which is similar to the adult respiratory distress syndrome (ARDS). We aim to summarize information pertinent to LTx-MV, as well as PGD, ARDS, and intraoperative MV and to synthesize these available data into recommendations. Based on the available evidence, we recommend lung-protective MV with low-tidal-volumes (≤6 mL/kg predicted body weight [PBW]) and positive end-expiratory pressure for the LTx-recipient. In our opinion, the MV strategy should be based on donor characteristics (donor PBW as a parameter of actual allograft size), rather than based on recipient characteristics; however this donor-characteristics-based protective MV is based on indirect evidence and requires validation in prospective clinical studies.

Lung transplantation in older patients?

OBJECTIVE

Age 65 years and older is generally considered a contraindication to lung transplantation. Our group has offered lung transplantation to select patients 65 years of age and older who lack other comorbid conditions. We sought to define the short- and medium-term outcome of lung transplantation in patients aged 65 years and older.

METHODS

We reviewed the records of our lung transplant recipients from March 2000 to September 2006. During this interval, 50 patients were 65 years or older at the time of transplantation. Fifty patients younger than 65 years were matched to the older cohort by means of propensity analysis. The demographics and perioperative and postoperative characteristics and survival of the 2 groups were compared.

RESULTS

Older patients were more likely to receive single-lung transplantation (older group: 76% vs younger group: 16%, P < .05) and nonstandard donor lungs (older group: 46% vs younger group: 28%, P = .06). The composite in-hospital morbidity rate was similar in the older and younger groups. There was no significant difference in the early oxygenation parameters, incidence of acute cellular rejection, or incidence of bronchiolitis obliterans syndrome between the 2 groups. The early survival of the older patients was 95.7% compared with 95.9% in the younger cohort (P = .73). The 1-year survival of the 2 groups was also similar (older group: 79.7% vs younger group: 91.2%, P = .16). The 3-year survival of the older and younger recipients was 73.6% and 74.2%, respectively (P = .64). There were 8 deaths in the older recipient group during the 1-month to 1-year posttransplantation interval, predominantly because of infections.

CONCLUSIONS

Lung transplantation can be performed in patients older than 65 years with acceptable clinical outcomes. The "increased" mortality of older patients between 1 month and 1 year after transplantation, predominantly from infectious causes, might be due to immunosenescence of older patients. This finding warrants adjustments in the immunosuppression protocol of older patients undergoing lung transplantation. The effect of offering lung transplantation to older patients on donor lung availability deserves further investigation.

A reinforced sternal wiring technique for transverse thoracosternotomy closure in bilateral lung transplantation: From biomechanical test to clinical application

OBJECTIVES

A high incidence of failure of transverse thoracosternotomy closure, involving the loops of wire cutting through the sternum, remains a significant morbidity after bilateral lung transplantation. We postulated that placing peristernal wires inside the usual longitudinal wires could prevent the longitudinal wires from cutting through the sternum. The aims of this study were to investigate the biomechanical and clinical efficacy of the proposed reinforced sternal closure technique.

METHODS

In vitro, 24 artificial sternal models were wired with the reinforced or conventional wiring techniques and were tested either by means of longitudinal distraction or anterior-posterior shear (n = 6 per group). In vivo, the 6-month outcomes of 70 bilateral lung transplantations, including 27 reinforced and 43 conventional wiring techniques, were assessed.

RESULTS

Reinforced wiring was stronger than conventional wiring for both longitudinal distraction (yield load: 585 +/- 60 vs 334 +/- 21 N [P = .03]; maximum load: 807 +/- 60 vs 525 +/- 34 N [P = .03]; postyield stiffness: 91.0 +/- 22.0 vs 32.8 +/- 11.8 N/mm [P = .04]) and anterior-posterior shear (yield load: 405 +/- 9 vs 364 +/- 16 N [P = .03]; postyield stiffness: 47.4 +/- 6.1 vs 27.5 +/- 5.1 N/mm [P = .04]). In multivariate analysis, the use of the conventional wiring technique (odds ratio, 5.38; P = .04) and osteoporosis (odds ratio, 18.31; P = .0005) were significant risk factors associated with sternal dehiscence. In the patients with osteoporosis (n = 25), the incidence of sternal dehiscence in the reinforced wiring group (4/16 [25%]) was significantly lower than that in the conventional wiring group (7/9 [78%], P = .02).

CONCLUSION

Osteoporosis is a significant risk factor for sternal dehiscence after bilateral lung transplantation. The new reinforced sternal wiring technique provides biomechanically superior fixation of the sternum and clinically reduces the incidence of sternal dehiscence in high-risk osteoporotic patients undergoing bilateral lung transplantation.

Early outcomes comparing Perfadex, Euro-Collins, and Papworth solutions in lung transplantation

BACKGROUND

Despite improved surgical techniques and medical management, primary graft dysfunction (PGD) remains a major cause of early morbidity and mortality after lung transplantation. Different types of lung preservation solutions have been developed and applied to clinical use; however, the relative clinical efficacy of these solutions to prevent PGD remains controversial. This study aimed to investigate the effect of the three solutions most commonly used (Perfadex [Vitrolife, Göteborg, Sweden], Papworth, and Euro-Collins [Baxter Healthcare, Old Toongabbie NSW, Australia]) on posttransplant outcomes.

METHODS

Early outcomes from 157 consecutive lung transplants (113 bilateral and 44 single) performed at The Alfred Hospital were compared across three preservation solutions.

RESULTS

Posttransplant oxygenation (p = 0.57), pulmonary vascular resistance (p = 0.34), intubation hours (p = 0.66), intensive care unit days (p = 0.34), severe PGD (grade 3) (p = 0.70), 30-day mortality (p = 0.87), and 3-month % predicted forced expiratory volume in 1 second (p = 0.58) were not statistically different; however, Perfadex trended toward superiority among the three solutions. After adjustment of donor, recipient, and operative factors in multivariate analysis, Perfadex was significantly associated with the prevention of moderate to severe PGD (grade 2 to 3) at 48 hours posttransplant (odds ratio = 0.26 [0.10 to 0.72], p < 0.01) compared with Papworth (odds ratio = 0.75 [0.32 to 1.75], p = 0.51) and Euro-Collins (reference) solutions.

CONCLUSIONS

Although any advantageous effects of Perfadex on early posttransplant outcomes were generally subtle and statistically nonsignificant, Perfadex prevented moderate to severe PGD. Switching preservation solution from Euro-Collins (or Papworth) to Perfadex would appear to usefully contribute to a strategy to reduce PGD in lung transplantation.

Does the presence of preoperative mild or moderate coronary artery disease affect the outcomes of lung transplantation?

BACKGROUND

Significant coronary artery disease (CAD) is an exclusion criterion for lung transplantation at most centers. However, the impact of preoperative noncritical CAD (single or multivessel mild <30% or moderate 30% to 50% stenosis) on the outcomes of lung transplantation is unknown.

METHODS

A retrospective review of 268 adult patients who underwent lung transplantation between June 1998 and June 2003 at Barnes-Jewish Hospital, a tertiary care center affiliated with Washington University School of Medicine, was performed.

RESULTS

Two hundred ten patients had coronary angiography performed as part of their pretransplantation evaluation. Among these patients, 177 patients had no CAD, and 33 patients (mild, 16; moderate, 17) had noncritical CAD. Patients with noncritical CAD were older (59 versus 55 years, p < 0.001) and had a higher prevalence of diabetes (24% versus 9%, p = 0.014) and systemic hypertension (58% versus 36%, p = 0.004) than patients without CAD. There was no significant difference in the underlying lung disease, other comorbidities, type of lung transplantation performed, early postoperative complications, and hospital or late mortality between recipients with or without CAD. Among the patients with noncritical CAD, there was no hospital mortality and no late cardiac mortality. Three recipients with preoperative moderate CAD developed late ischemic cardiac events, and revascularization was performed in 2 of these recipients. Long-term survival was similar among recipients with or without preoperative CAD.

CONCLUSIONS

Preoperative noncritical (mild or moderate) CAD was not associated with increased perioperative morbidity or mortality, and it did not adversely affect short-term or long-term survival. Late ischemic events developed in 18% of the recipients with moderate CAD disease with no effect on mortality.

Techniques of Reconstruction for Inadequate Donor Left Atrial Cuff in Lung Transplantation

BACKGROUND

An inadequate donor left atrial (LA) cuff due to an anatomical abnormality of the pulmonary vasculature or technical errors at the time of procurement can exclude the lungs from transplant. This study aims to describe the incidence, efficacy, and various techniques of LA cuff reconstruction in lung transplantation.

METHODS

A total of 637 pulmonary venous anastomosis in 405 consecutive lung transplants from January 1995 to July 2005 were reviewed. Comparison between the patients who required LA cuff reconstruction (reconstruction group) or who did not (no-reconstruction group) was made in posttransplant outcomes.

RESULTS

An overall incidence of requirement of LA cuff reconstruction was 2.7% (4% on the right, 1% on the left, p = 0.03). Seventy-one percent of LA inadequacy was corrected using a pericardial patch on the anterior LA cuff wall; the remainder required complicated reconstruction for separated/short pulmonary veins to create a new LA cuff. There was no significant difference between the reconstruction and no-reconstruction groups, respectively, in oxygenation (329 +/- 28, 337 +/- 10, p = 0.81), duration of intubation and intensive care unit stay (p = 0.54, p = 0.89, respectively), 30-day mortality (12%, 6%, p = 0.30), and 5-year survival (57%, 52%, p = 0.80).

CONCLUSIONS

Inadequate donor LA cuff is an infrequent but potentially serious complication in lung transplantation. Donor LA cuff reconstruction using donor pericardium or pulmonary artery remnant is a useful technique to salvage surgically marginal lungs without affecting early and late posttransplant outcomes. These lungs should not be excluded from transplantation.